Benign prostatic hyperplasia
Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is a condition in which the prostate gland becomes enlarged. The size of the gland does not necessarily predict symptom severity. Some men with minimally enlarged prostate glands experience many symptoms while other men with much larger glands have few symptoms. BPH is very common among older men, affecting about 50% of men over age 60 and 85% of men over age 80.
The symptoms associated with BPH are collectively called lower urinary tract symptoms (LUTS). These are generally classified as either voiding (obstructive) symptoms or storage (irritative) symptoms.
Common symptoms of BPH include:
Urinary retention (inability to void) is a serious symptom of severe BPH that requires immediate medical attention.
BPH is not a cancerous or precancerous condition. It rarely causes serious complications, and men often have a choice whether to treat it immediately or delay treatment. Treatment options include medications and surgery. Alpha-blockers and 5-alpha-reductase inhibitors (5-ARIs) are the main types of drugs used for BPH treatment.
5-ARIs and Prostate Cancer
A controversial matter is whether 5-ARIs help protect against prostate cancer. Studies have suggested that 5-ARIs lower a man's overall risk for developing prostate cancer. However, the FDA has advised that these drugs may actually increase the risk of developing high-grade aggressive types of prostate cancer.
Benign prostatic hyperplasia (BPH), also called enlarged prostate, is noncancerous cell growth of the prostate gland. It is the most common noncancerous form of cell growth in men. BPH is not a precancerous condition and does not lead to prostate cancer. However, it is possible to have BPH and also develop prostate cancer.
The prostate gland is an organ that surrounds the urinary urethra in men. It secretes fluid that mixes with sperm to make semen. The urethra carries urine from the bladder and sperm from the testes to the penis.
Hyperplasia is a medical term that refers to an abnormal increase in cells. As prostatic cell growth progresses, it can lead to enlargement of the prostate gland. The enlarged prostate can squeeze the urinary tube (urethra), causing urinary symptoms. These urinary difficulties are part of a group of symptoms called collectively lower urinary tract symptoms (LUTS).
Not all men with BPH have LUTS, and not all men with LUTS have BPH. Lower urinary tract symptoms can also be caused by many other conditions including overactive bladder, urinary tract infections, prostatitis (inflammation of the prostate), and nerve damage that weakens the bladder.
About a third of men with BPH have LUTS that interfere with their quality of life. The size of the prostate gland does not necessarily relate to the severity of a patient's symptoms.
The Prostate Gland
Description of the Prostate Gland
The prostate is a walnut-shaped gland located below the bladder and in front of the rectum. It wraps around the urethra (the tube that carries urine through the penis).
Functions of the Prostate Gland
The prostate gland provides the following functions:
Changes During the Lifespan
The prostate gland undergoes many changes during the course of a man's life. At birth, the prostate is about the size of a pea. It grows only slightly until puberty, when it begins to enlarge rapidly. It reaches normal adult size and shape, about that of a walnut, when a man is in his early 20s.
The gland generally remains stable until about the mid-40s, when, in most men, the prostate begins to grow again through a process of cell multiplication (hyperplasia). BPH is common in older men. The likelihood of developing an enlarged prostate increases with age.
The Process of Urination
The process of urination is complicated:
Doctors are not exactly sure what causes benign prostatic hyperplasia (BPH). The changes that occur with male sex hormones as part of the aging process appear to play a role in prostate gland enlargement.
Androgens (male hormones) affect prostate growth. The most important androgen is testosterone, which is produced in the testes throughout a man's lifetime. The prostate converts testosterone to another powerful androgen, dihydrotestosterone (DHT).
DHT stimulates cell growth in the tissue that lines the prostate gland (the glandular epithelium) and is the major cause of the rapid prostate enlargement that occurs between puberty and young adulthood. DHT is a prime suspect in prostate enlargement in later adulthood.
The female hormone estrogen may also play a role in BPH. (some estrogen is always present in men.) As men age, testosterone levels drop, and the proportion of estrogen increases, possibly triggering prostate growth.
Age is the major risk factor for BPH. About half of men develop BPH by age 60, and up to 90% of men in their 70s and 80s have BPH symptoms. It is uncommon for BPH to cause symptoms before age 40.
A family history of BPH appears to increase a man's chance of developing the condition.
Other Risk Factors
Some evidence indicates that the same risk factors associated with heart disease and type 2 diabetes may increase the risk for development or progression of BPH. These risk factors include obesity, physical inactivity, high blood pressure, and low levels of HDL (good) cholesterol.
Lower urinary tract symptoms (LUTS) are categorized either as voiding (formerly called obstructive) or storage (formerly called irritative) symptoms. BPH is often, but not always, the cause of LUTS, largely the voiding symptoms. Other medical conditions, such as bladder problems, can also cause these symptoms.
Some men with BPH may have few or no symptoms. The size of the prostate does not determine symptom severity. An enlarged prostate may be accompanied by few symptoms, while severe LUTS may be present with normal or even small prostates.
Voiding (Obstructive) Symptoms
Voiding symptoms can be caused by an obstruction in the urinary tract, which may be due to BPH. Obstruction is the most serious complication of BPH and requires medical attention. Voiding symptoms include:
Storage (Irritative) Symptoms
Storage symptoms, also referred to as filling symptoms, include:
Urine flows from the kidney through the ureters into the urinary bladder where it is temporarily stored. As the bladder becomes distended with urine, nerve impulses from the bladder signal the brain that it is full, giving the individual the urge to void. By voluntarily relaxing the sphincter muscle around the urethra, the bladder can be emptied of urine. Urine then flows out through the urethra.
Acute urinary retention (inability to void) is a serious complication of severe BPH that requires immediate medical attention. Urinary retention can be a sign of obstruction in the bladder.
Bladder outlet obstruction (BOO) is a blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra, the tube that carries urine out of the body. BPH is a common cause of this condition.
Even without complete obstruction, urinary retention can increase the risk for other complications including:
A doctor makes a diagnosis of BPH based on description of symptoms, medical history, physical examination, and various blood and urine tests. If necessary, your doctor may refer you to a urologist for more complex test procedures.
Some diagnostic tests are used to rule out cancers of the prostate or bladder as the cause of symptoms. In some cases, symptoms of prostate cancer can be similar to those of BPH. Tests may also be performed to see if BPH has caused any kidney damage.
The doctor will ask about your personal and family medical history, including past and present medical conditions. The doctor will also ask about any medications you are taking that could cause urinary problems.
Digital Rectal Exam
The digital rectal exam is used to detect an enlarged prostate. The doctor inserts a gloved and lubricated finger into the patient's rectum and feels the prostate to estimate its size and to detect nodules or tenderness. The exam is quick and painless. The test helps rule out prostate cancer or problems with the muscles in the rectum that might be causing symptoms, but it can underestimate the prostate's size. It is never the sole diagnostic tool for either BPH or prostate cancer.
Other Physical Examinations
The doctor will press and manipulate (palpate) the abdomen and sides to detect signs of kidney or bladder abnormalities. The doctor may test reflexes, sensations, and motor response in the lower body to rule out possible nerve-related (neurologic) causes of bladder dysfunction.
Prostate Specific Antigen (PSA) Test
Your doctor may recommend a prostate specific antigen (PSA) test to check for prostate cancer. PSA is a substance made by cancerous and non-cancerous prostate cells. A PSA test measures the level of prostate-specific antigen (PSA) in the blood. The PSA test is a widely used but controversial screening test for prostate cancer. High PSA levels may indicate prostate cancer, but BPH itself often raises PSA levels. And, some drugs used to treat BPH can decrease PSA levels.
A urinalysis can detect signs of bleeding or infection. A urinalysis involves a physical and chemical examination of a urine sample. A urinalysis also helps rule out bladder cancer.
To determine whether the bladder is obstructed, an electronic test called uroflowmetry measures the speed of urine flow. To perform this test, the patient urinates into a special toilet equipped with a measuring device. A reduced flow may indicate BPH. However, bladder obstruction can also be caused by other conditions including weak bladder muscles and problems in the urethra.
Cystoscopy, also called urethrocystoscopy or cystourethroscopy, is a test performed by a urologist to check for problems in the lower urinary tract, including the urethra and bladder. The doctor can determine the presence of structural problems including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or bladder stones. The test may also identify bladder cancer, causes of blood in the urine, and infection.
In this procedure, a thin tube with a light at the end (cytoscope) is inserted into the bladder through the urethra. The doctor may insert tiny instruments through the cytoscope to take small tissue samples (biopsies). Cytoscopy is typically performed as an outpatient procedure, usually in the office. The patient may also be given sedation and local, spinal, or general anesthesia, typically in an outpatient surgical setting.
Ultrasound is a painless procedure that can give an accurate picture of the size and shape of the prostate gland. Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:
Postvoid Residual Urine
The postvoid residual urine volume (PVR) test measures the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a bladder scanner. This is a type of ultrasound that measures the amount of urine inside the bladder. If a scanner is not available, a small tube called a catheter may need to be passed into the bladder to drain any urine left behind and measure the amount.
Ruling Out Other Causes of Symptoms
In addition to prostate cancer, other conditions and factors can cause lower urinary tract symptoms (LUTS) similar to those associated with BPH:
Treatment for BPH depends in part on the severity of symptoms. Men who have few or minimal symptoms may consider trying a period of "watchful waiting" before choosing drug (or surgical) treatment:
Deciding Between Treatment and Watchful Waiting
The choice between watchful waiting and treatment often depends on symptom severity. The American Urological Association's BPH Symptom Score uses seven questions to evaluate a patient's urinary symptoms during the past month. (The International Prostate Symptoms Score is another index that is also used.) The questions are:
Responses for the first six questions are scaled from "not at all" to "almost always." (The last question uses answers ranging from "none" to "5 or more times.") Each response is assigned a number on a scale of 0 to 5 and totaled into a symptom score. The symptom score can fall anywhere between 0 and 35.
Patients with mild symptoms will have low scores and may decide to delay treatment. Higher scores indicate more severe symptoms. Treatment can reduce the score:
Your doctor can discuss with you the various treatment options and the likelihood of symptom relief they may provide. All treatments have various side effects, which need to be taken into consideration. Quality of life is as important as symptom severity.
In general, there is no reason to treat BPH with medications unless symptoms become very bothersome. The size of the prostate, determined by exam or ultrasound, cannot indicate the need for medications. Evidence suggests that:
Surgery is an option for men with moderate-to-severe symptoms who have not been helped by medication. There are many types of surgical treatment for BPH. Transurethral resection of the prostate (TURP) is the standard procedure, but less invasive procedures, particularly those using heat or lasers to destroy prostate tissue, are becoming more common.
The most common reason for choosing surgery is obstruction of the bladder outlet, which causes urinary retention. Surgery may also be a reasonable option when BPH is clearly related to one or more of the following conditions:
Increased urinary flow and reduced urine retention are the greatest improvements resulting from surgery. Often, however, the benefits of surgery are not necessarily permanent, as the prostate can regrow.
General Lifestyle Recommendations
Certain lifestyle changes may help relieve symptoms and are particularly important for men who choose to avoid surgery or drug therapy. They include:
Avoiding Medications that Aggravate Symptoms
Decongestants and Antihistamines
Men with BPH should avoid any medications for colds and allergies that contain decongestants, such as pseudoephedrine (Sudafed, generic). Such drugs, known as adrenergics, can worsen urinary symptoms by preventing muscles in the prostate and bladder neck from relaxing to allow urine to flow freely. Antihistamines, such as diphenhydramine (Benadryl, generic), can also slow urine flow in some men with BPH.
Diuretics are drugs that increase urine production by the kidneys. They are often used to treat high blood pressure. If you take a diuretic, you may want to talk to your doctor about reducing the dosage or switching to another type of drug. No one should stop taking a diuretic without medical supervision.
Other drugs that may worsen symptoms are certain antidepressants and drugs used to treat spasticity.
Pelvic Floor Muscle Training
Pelvic floor muscle exercises, also called Kegel exercises, may help men prevent urine leakage, particularly after surgical procedures. These exercises strengthen the pelvic floor muscles that both support the bladder and close the sphincter.
Performing the Exercises
Since the muscle is internal and sometimes hard to isolate, doctors often recommend practicing while urinating:
Dietary factors do not appear to play much of a role in BPH risk or severity. Still, because obesity and high body mass index (BMI) are possible risk factors, good nutrition is important. A heart-healthy diet rich in vegetables fruits, and whole grains -- along with regular physical activity -- can help with weight control and reduce BPH risk.
Herbs and Supplements
Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the FDA to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctor before using any herbal remedies or dietary supplements.
Popular herbal and dietary supplement treatments for BPH include:
Patients should be aware that high doses of zinc supplements may increase the risk and progression of BPH.
The two main drug classes used for BPH are:
Because alpha-blockers and 5-ARIs work in different ways, some patients find that a combination of the two controls symptoms better than a single drug alone. Other men find that a single drug is adequate for symptom control.
Alpha-adrenergic antagonists, commonly called alpha-blockers, relax smooth muscles in the prostate and make it easier for urine to flow. They quickly improve symptoms, usually within days. Because these drugs are short-acting, symptoms return once a man stops taking the medication. Alpha-blockers do not shrink the size of the prostate or change PSA levels.
Alpha-blockers are generally referred to as either nonselective or selective:
Alpha-blockers can cause headache, and stuffy or runny nose. Alpha-blockers can reduce blood pressure, which may cause dizziness, lightheadedness, and fainting. Orthostatic hypotension, a sudden drop in blood pressure when standing, can occur and increases the risk of falling. Taking the medication close to bedtime can help reduce these side effects.
Because of the reduced blood pressure side effect, do not take nonselective alpha blockers with the phosphodiesterase (PDE5) inhibitors used for erectile dysfunction (sildenafil [Viagra], tadalafil [Cialis],vardenafil [Levitra], or avanafil [Stendra]). Men who take selective alpha blockers may be able to use erectile dysfunction pills with guidance from a doctor. (Men may experience a decreased ejaculate while taking these drugs. However, erectile dysfunction is not a usual side effect of alpha-blockers, as it is with finasteride and dutasteride.)
A special concern for tamsulosin, and other selective alpha-blockers, is that they are associated with a condition called intraoperative floppy iris syndrome (IFIS). IFIS is a loss of muscle tone in the iris that can cause complications during cataract surgery. Patients who are planning cataract or other eye surgery should be sure to inform their doctors prior to the surgery. IFIS appears more likely to occur with selective alpha-blockers than nonselective alpha blockers.
Some research suggests that tamsulosin may double the risk for low blood pressure (hypotension) severe enough to require hospitalization. The risk appears to be highest in the first 8 weeks after starting or restarting treatment with the drug.
5-Alpha-Reductase Inhibitors (5-ARIs)
The prostate gland contains an enzyme called 5 alpha-reductase that converts testosterone to another androgen called dihydrotestosterone. Drugs known as 5-alpha-reductase inhibitors (5-ARIs), block this enzyme and thus reduce dihydrotestosterone in the prostate thereby preventing prostate growth.
The 5-ARIs used for treating BPH are:
Because 5-ARIs help shrink enlarged prostates, they are most effective in reducing symptoms in men with very large prostates. These drugs take several months before they have an effect so men may not notice any signs of improvement for 3 to 6 months and full effect may not be reached for 12 months.
Finasteride and dutasteride can cause erectile dysfunction, lowered sexual drive (libido), and ejaculation and orgasm disorders. These drugs can reduce the volume and quality of semen released during ejaculation. These sexual side effects may sometimes persist even after the drug is discontinued. (A positive side effect of finasteride is possible reduction of hair loss related to male hormones and, in some cases, hair growth in men with mild-to-moderate male pattern baldness.)
These drugs decrease prostate-specific antigen (PSA) levels, which may mask the presence of prostate cancer. To resolve this problem, doctors calculate PSA levels in men taking these drugs by doubling the PSA values. This doubling equation helps provide an accurate measurement. The FDA advises doctors that an increase in PSA (even if it's in a normal range) while taking this drug may indicate the presence of prostate cancer.
A controversial matter is whether 5-ARIs help protect against prostate cancer. Studies have suggested that 5-ARIs lower a man's overall risk for developing prostate cancer. However, based on these studies, the FDA advises that these drugs may actually increase the risk of developing high-grade aggressive types of prostate cancer.
The 5-ARIs are not approved for prostate cancer prevention. Men who take these drugs for BPH should discuss this issue with their doctors. The FDA recommends that doctors rule out other urologic conditions, including prostate cancer, which may mimic BPH before prescribing 5-ARIs for BPH treatment.
Anticholinergic drugs, also called antimuscarinics, such as tolterodine (Detrol, generic) may be helpful for some patients. For treatment of BPH, they may be prescribed either alone or in combination with an alpha-blocker drug. They are more likely to help men with frequency, urgency, and incontinence caused by an overactive bladder.
Tadalafil (Cialis) is approved for treating BPH either alone or when it occurs along with erectile dysfunction. Tadalafil should not be used in combination with alpha-blockers without careful consideration and monitoring for excessive blood pressure lowering. Like all PDE5 inhibitor drugs used for erectile dysfunction, men who take nitrate drugs should not take tadalafil.
Several surgical approaches are used to treat BPH. Reasons for performing prostate surgery include:
Surgical options include invasive and minimally invasive procedures. The choice of which surgical procedure to use depends on various factors, including a man's age, size of the prostate, and general health.
The most effective surgical procedure, transurethral resection of the prostate (TURP), is also the most invasive and has the highest risk for serious complications. However, because it is more effective than less invasive procedures, TURP remains the procedure of choice for many doctors.
Minimally invasive procedures use laser or some other form of heat to destroy excess prostate tissue. Although minimally invasive procedures may be an appropriate choice for some patients, including younger men, none to date have proven superior to TURP.
Transurethral Resection of the Prostate (TURP)
Transurethral resection of the prostate (TURP) involves surgical removal of the inner portion of the prostate, where BPH develops. It is the most common surgical procedure for BPH, although the number of procedures has dropped significantly over the past decades because of the increased use of effective medications and the increasing use of laser procedures.
The surgeon inserts a thin fiber-optic tube called a resectoscope into the urethra. No incision or stitches are needed. The resectoscope is a type of endoscope. It has a telescope lens to help the surgeon see the prostate gland. The surgeon uses a wire cutting loop inserted into the resectoscope to cut away excess prostatic tissue using a monopolar electrocautery, and water solutions are used to flush away the excised matter. TURP usually requires a 1 to 2 day hospital stay. A newer version called bipolar TURP uses a bipolar electrocautery instead.
A Foley catheter generally remains in place for 1 to 3 days after surgery to allow urination. This device is a tube inserted through the opening of the penis to drain the urine into a bag. The catheter can cause temporary bladder spasms that can be painful. The catheter may be removed while the patient is in the hospital or after they are sent home.
Urine flow is stronger almost immediately after most TURP procedures. After the catheter is removed, patients often feel some pain or sense of urgency as the urine passes over the surgical wound. These sensations generally last for about a week and then gradually subside. Complete healing takes about 2 months. The following are some tips for speeding recovery and avoiding complications:
The TURP procedure is generally safe but there are some risks for short- and long-term complications.
Immediate short-term complications after surgery may include:
Long-term complications after surgery may include:
Other Invasive Surgical Procedures
Transurethral Incision of the Prostate (TUIP)
In TUIP, the surgeon makes only one or two incisions in the prostate, causing the bladder neck and the prostate to spring open and reduce pressure on the urethra. TUIP is generally reserved for men with minimally enlarged prostates who have obstruction of the neck of the bladder.
TUIP is less invasive than TURP, has a lower rate of the same complications (particularly retrograde ejaculation), and usually does not require a hospital stay. More studies are still needed, however, to determine whether they are comparative in long-term effectiveness.
In simple prostatectomy, the enlarged prostate is removed through an open incision in the abdomen using standard surgical techniques. This is major surgery and requires a hospital stay of several days. Simple prostatectomy is used only for severe cases of BPH, when the prostate is severely enlarged, the bladder is damaged, or other serious problems exist. Some patients need a second operation because of scarring. Side effects of simple prostatectomy can include erectile dysfunction and urinary incontinence. This surgery can be performed through an incision in the lower abdomen or keyhole incisions for robot-assisted laparoscopy.
Laser technology is used for removal of prostate tissue. Laser procedures can mostly be done on an outpatient basis, and there is little risk for bleeding. The procedure involves passing a small tube with a tiny camera and the laser fiber through the urethra of the penis. The procedure is performed under spinal, epidural, or general anesthesia.
Laser procedures have a faster recovery time and less risk of incontinence than invasive surgical procedures, but their long-term effectiveness is less clear. Laser surgery may not be appropriate for men with larger prostates. The procedures use various forms of heat to destroy cells with mechanisms that range from coagulation to complete vaporization:
Other Less Invasive Procedures
These minimally invasive procedures carry fewer risks for incontinence or problems with sexual function than invasive procedures, but it is unclear how effective they are in the long term.
Transurethral Microwave Thermotherapy (TUMT)
Transurethral microwave thermotherapy delivers heat using microwave pulses to destroy prostate tissue. A microwave antenna is inserted through the urethra with ultrasound used to position it accurately. The antenna is enclosed in a cooling tube to protect the lining of the urethra. Computer-generated microwaves pulse through the antenna to heat and destroy prostate tissue. When the temperature becomes too high, the computer shuts down the heat and resumes treatment when a safe level has been reached. The procedure takes 30 minutes to 2 hours, and the patient can go home immediately afterward.
Transurethral Needle Ablation (TUNA)
Transurethral needle ablation is a relatively simple and safe procedure, using needles to deliver high-frequency radio waves to heat and destroy prostate tissue.
Transurethral Electrovaporization (TUVP)
Transurethral electrovaporization uses high voltage electrical current delivered through a resectoscope to combine vaporization of prostate tissue and coagulation that seals the blood and lymph vessels around the area. Deprived of blood, the excess tissue dies and is sloughed off over time.
Prostatic Stents and Implants
Prostatic stents used for BPH are flexible mesh tubes that are inserted into the urethra. Typically, the insertion procedure takes only 15 minutes. Patients need only regional anesthetic and mild sedation. There is minimal recuperation and no overnight hospital stay. Unfortunately, stents often need to be removed later because of poor placement or complications, including irritation when urinating, urinary tract infections, stone formation, and treatment failure. At this point, stents seem best suited for high-risk surgical patients or those with a limited life expectancy.
The UroLift system is the first permanent implant to treat men ages 50 and older with BPH. The implants are placed during a minimally invasive procedure and help to keep the lobes of the enlarged prostate gland open to improve urine flow. The device has not been compared directly in studies with other established treatments. It appears to have less impact on sexual health than other surgical procedures.
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